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Surgical Stabilization For Thumb Base Hyperlaxity; A Randomized Comparison Of The Dorsal And Volar Approach With A Cohort Of The Volar Approach
K.R. Spekreijse, MD1; G.M. Vermeulen, MD, PhD2; T.M. Moojen, MD, PhD2; H.P. Slijper, PhD1; R.W. Selles, PhD1; S.E.R. Hovius, MD, PhD1; R. Feitz, MD2
1Plastic Surgery, Erasmus MC, Rotterdam, Netherlands; 2Plastic Surgery, Xpert Clinic, Hilversum, Netherlands

Objective: Surgical stabilization for hyperlaxity of the carpometacarpal joint of the thumb was introduced by Eaton in 1987 using the flexor carpi radialis (FCR) tendon to reconstruct the beak ligament. However, evidence is scarcely available on the outcome for this patient group. In this study, we present the overall outcome of surgical stabilization in 57 thumbs. Within this group, we compared a volar approach with a dorsal approach in a small pilot RCT.

Methods: We followed all patients treated for chronic non-degenerative hyperlaxity of the thumb complaining of pain and impaired function due to pinch instability where conservative therapy failed. Sixteen of these patients were randomly assigned to either a variation of the volar technique by Eaton using the FCR to stabilize the beak ligament or a dorsal technique using the ECRL for stabilization of the intermetacarpal ligament. All patients received standard postoperative therapy. At baseline and at 3 months and 12 months after surgery we measured pain, strength, and ADL function using the Michigan Hand Questionnaire (MHQ) and the DASH. Generalized estimating equations statistics were used to compare repeated measurements over time in 2 groups.

Results: 54 Patients (57 thumbs) had a surgical stabilization of the thumb. We found a significant improvement in the visual analogue score for pain (mean±SD from 61±3 to 33±3 after 3 months and 23±6 after 1 year, p<0.001) and MHQ score (54±2 to 64±4 to 71±2, p<0.001). For secondary outcomes, the treatment improves after 1 year grip strength (22±1kg to 29±1kg, p<0.001) and key pinch strength 5.1±0.5kg to 7.0±0.6kg, p<0.001). The patients could return to work or activities within an average of 8(±7) weeks.

The pilot randomized trial comparing the volar and dorsal technique was abandoned after including 8 patients in each group because of a significant increasement in pain in the dorsal group after 3 months (43±8 compared to 26±6, p<0.003). The secondary outcome measurements after 1 year showed better function in the volar group (DASH) (35±11 to 46±8 in the dorsal approach compared with 38±6 to 24±7 in the volar group, p<0.124), higher grip strength (17±2 to 22±3kg compared with 18±3 to 29±2, p<0.199) and higher key pinch strength.

Conclusion: Surgical stabilization of the thumb base is an effective method for patients suffering from thumb hyperlaxity and results in pain relief, improved strength and improved function. The randomized controlled trial was abandoned because of significantly more pain in the dorsal group.

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